Download ABSTRACT Topic: literature review investigating strategies ... non-compliance in mental health.

ABSTRACT
Topic: literature review investigating strategies to overcome medication
non-compliance in mental health.
Background: The proof of non-compliance
being the foremost yet
avoidable reason for relapse is well documented and a number of strategy
aimed at enhancing compliance have been investigated. This literature
review aims to review research studies that have investigated strategies to
overcome non-compliance with medication in mental health.
Method: Research journals from 1999-2010 were selected and studied to
find consistent and contrasting views. There themes namely educational
intervention, Compliance therapy and the role of mental health nurse were
identified by the author; these themes will be discussed throughout this
literature review.
Findings: Literature revealed that Education seems to increase patients’
knowledge of their illness and treatment but does not promote compliance,
however
strategies
like
compliance
therapy,
based
on
cognitive-
behavioural therapy and medication management training package for
nurses seem to be efficient in improving compliance and prevent relapse.
1
TABLE OF CONTENT
PAGE NUMBER
Abstract
1
Introduction
2-3
Search strategy
4
Educational interventions
5-7
Compliance therapy
8-10
The role of the mental health nurse
11-12
Conclusion
13-14
Recommendation
15
Referances
16-17
2
INTRODUCTION
Literature review is defined as a summary of research on a topic of
interest often prepared to put a research problem in context (Polit and
Beck 2008).
Antipsychotic medication in the treatment of schizophrenia has proved to
be effective however a lot of people with schizophrenia do not comply with
their prescribed medication regimen, this results to a significant decline in
the promise of antipsychotic medication (Zygmunt et al. 2002). The rates
of medication non-adherence have been found to approach 50% among
patients with schizophrenia during the first year after discharge from
hospital, the rates may even be higher taking into account that the
estimates do not include individuals who refuse treatment or drop out of
follow-up studies and in spite of atypical antipsychotic medications having
less serious and disabling side effects, there is little proof of any progress
made at increasing compliance. (Zygmunt et al. 2002). Parashos et al.
(2000) argued that the prevalence of non compliance with antipsychotic
medication in patients with schizophrenia is at 50%.
Non-compliance with medication means failure on the part of a client to
follow the recommendations of a mental health professional with regards
to their medication,
however modern health care is concerned with
working with clients and has therefore suggested that ‘concordance’ should
replace the use of the word ‘compliance’. Concordance projects patient
rights, need for information, the importance of two-way communication
and decision-making such as stopping medication even if clinicians do not
agree with the decision (Gray et al. 2002).
3
According to Kumar and Sedgwick (2001) the reasons for non-compliance
include intolerable side-effects, cost of medication, psychotic explanations
which include delusions and hallucinations. In addition, Parashos et al. also
identified social pressure and lack of insight as reason for noncompliance.
The consequences of non-compliance according to Parashos et al. (2000)
include frequent relapses, poor outcome and poor quality of life for
patient, increased burden on the relatives and increased financial cost to
society.
Little
research
interventions
to
efforts
have
improve
been
made
compliance
with
at
devising
prescribed
and
testing
antipsychotic
medication in spite of the relationship between good compliance and
outcome. (Gray et al. 2002). According to Gray et al. (2002) various
interventions have been evaluated in patients who present with both
physical and mental illnesses, although much of the research has focused
on acute psychosis or schizophrenia.
This literature review aims to investigate research studies that have
investigated strategies to overcome non-compliance with antipsychotic
medications. The author’s rationale for choosing this topic is because of
the high rate of non-compliance and relapse resulting in the revolving door
phenomena in psychiatric hospitals (Gray et al. 2002).
4
SEARCH SRATEGY
The author utilized electronic searches to gather relevant articles. These
databases include CINAHL, PubMED, Google Scholar and PsycINFO
Pubmed.
The
search
terms
used
were
antipsychotic
medication,
compliance, concordance, adherence, schizophrenia, interventions, mental
health and psychiatric nurse. 17 Articles were helpful from these searches.
Articles selected are dated from 1999 to 2010. The author had to look this
far in order to gain better understanding of the background of the studies.
Of the 17 articles found one was qualitative, twelve were quantitative,
three were literature reviews and one was anecdotal. The literatures
originated from Britain, Denmark, Ireland, Australia Thailand, Germany,
Italy, and Amsterdam
Themes from the literature are educational intervention, compliance
therapy and medication management. The literature will be review under
these themes.
5
Educational interventions
According to Gray et al. (2002) the aim of educational intervention is to
provide patients with information regarding their illness and medication
with the aim of increasing understanding and promoting compliance.
Kavanagh et al. (2003) state that a lot of psychiatric patients have no
knowledge about medications prescribed to them. The focus of this theme
is therefore to evaluate the benefit of clients’ education on medication
compliance.
Kavanagh et al. (2003) conducted a qualitatitive study using experimental
design with a convenient sample size of 15 participants in a psychiatric
intensive care unit in Britain. The study aimed at exploring the
effectiveness of a medication group on knowledge about drug treatment as
well as insight and drug adherence. Data was collected by assessing
patients before and after attending the educational groups using five
measures namely UMQ, (Understanding of
Medication Questionnaire
designed to measure knowledge of anti-psychotic treatment) SAIE,
(Expanded Schedule for Assessment of insight, which has components of
treatment compliance, awareness of illness and ability to re-label psychotic
symptoms) Compliance Rating Scale, (a seven- point rating scale
completed by the patients primary nurse) ROMI,( Rating of Medication
Influence, an instrument designed to assess patients’ subjective reason for
compliance, and non-compliance) BPRS, (Brief Psychiatric Rating Scale, a
semi-structured interview for the major psychiatric symptoms). The
validity of this tool was not mentioned in the research. Maneesakorn
(2007) argues that there is no valid gold standard measure of compliance.
The findings of this study revealed that though there was an increase in
insight due to the education session, there was no effect on compliance
6
compared with the group who did not attend any education group. This
research also found that group education regarding drug issue is effective
in the increase of insight even when given to acutely ill patients. The
finding of this study can not be generalised due to small sample
population. Further evidence to support this finding is provided by
Merinder et al. (1999) in a quatitative research using randomized
controlled trial and sample size of 46 patients and 36 relatives conducted
in a community mental health centre in Denmark aimed at probing the
effectiveness of an eight-session educational intervention for patients with
schizophrenia and their family on variables which include compliance. The
study found that a short patients and relative education program seems to
influence knowledge and some aspect of satisfaction but does not seem to
be
enough
to
improve
important
variables
such
as
compliance,
psychopathology, insight or psychosocial functioning. Merinder et al.
(1999) also concluded that educational intervention without behavioural
elements do not seem able to reduce relapse. Both studies suggest that
though educational interventions are effective in the improvement of
patient
knowledge
they
don’t
provide
any
significant
impact
on
compliance. This could mean that group interventions are not the most
effective method of providing patients with information regarding their
treatment (Gray et al. 2002).
In contrast to Kavanagh et al. (2003) and Merinder et al. (1999) finding,
Parashos et al. (2000) in a quantitative research aimed at investigating
reasons for non – compliance from patients and their relative perspective
sampled forty-five stabilised patients and their relatives with the use of
anonymous questionnaires. The research found that the most important
cause of non-compliance from patients and relative opinion was the lack of
knowledge about the illness and compliance was noticed to improve by
7
30% after a series of psychoeducation sessions and by the provision of
knowledge concerning medication. However the findings of this study can
not be generalized because the population sample was not randomly
selected. It should be noted however that questionnaires were deposited in
a box located in a specific room in the centre’s building so as to
accurate and honest responses.
ensure
Similarly, Peveler et al. (1999) in a
randomised controlled trial with 250 participants in a primary care hospital
in Wessex, United Kingdom, aimed at evaluating two different method of
improving compliance to antidepressant medication i.e. drug counseling or
information leaflet. This study found that counseling about drug treatment
significantly improved compliance. It is however worthy of note that the
participants in this research were stabilized unlike the sample population in
Kavanagh and Merinder et al.’s studies.
Interestingly Gray (2000) in a quantitative research and a randomized
controlled trial of 44 patients aimed at testing the hypothesis that brief
patient education is more effective than routine care in enhancing insight
and attitudes towards treatments in patients taking clozapine. Patients
received three sessions of one-one educational intervention in a room in
the hospital ward. Patients were assessed blind by a research worker who
was not involved in delivering the intervention or their standard care preintervention, and also after five weeks, using two standardized, valid and
reliable self-report scales. The Result of this study revealed that
compliance did not improve with this intervention. This negative finding
could be attributed to the fact that patients on clozapine tend to be more
disabled by their illness (Gray, 2000). It is reasonable from the above
findings to conclude that although simple educational interventions is
effective in improving patients knowledge about medication they are
generally not effective in promoting compliance.
8
Compliance therapy
Interventions may need to look into other factors which influence
compliance if improvement of clients understanding about their medication
does not promote compliance. One of such interventions is compliance
therapy devised by Kemp et al. (1996, 1998, as cited by Gray et al. 2002,
p. 282). Compliance therapy is based on motivational interviewing and
cognitive-behavioural techniques (Donohoe, 2006). Concordance therapy
involves patients in making decision that are right for them, instead of
trying to get them to obey professional advice. This theme will focus on
outcome of studies carried out on this intervention.
O’ Donnell et al. (2003) in a quantitative research study using randomised
controlled trial with 56 randomly selected participants in a large hospital in
Dublin Republic of Ireland, aimed at examining the effectiveness of
compliance therapy for improving compliance to prescribed drug treatment
among patients with schizophrenia. Structured clinical interview was used
in data collection by assessing patients’ subjective response and attitude
to antipsychotic medications. Symptoms, overall level of functioning,
insight and quality of life were measured. Five sessions of compliance
therapy lasting 36 minutes each was administered to the experimental
group.
These
sessions
addressed
the
patient’s
illness
history,
understanding of illness, and ambivalence to treatment, maintenance
medication and stigma. However the control patients received non-specific
counseling
without
any
discussions
regarding
their
medications.
Participants were re-assessed one year after intervention by a researcher
blind to the type of intervention delivered. Assessment involved same
variables assessed at baseline but included patients psychiatric admissions
9
one and two years after entering the trial. The outcome of this study
revealed that compliance therapy does not have any advantage over non
specific therapy for patients with schizophrenia in terms of patience
compliance to treatment, attitude to medication, insight, symptom, global
social functioning, quality of life, or re-admission to hospital. This result is
consistent with Gray et al.’s (2006) large-scale quantitative research using
300 participants in a multi-centered randomised controlled trial which took
place in routine general adult psychiatric hospitals in four locations namely
Germany, Italy, Amsterdam and London, with the aim of examining the
effectiveness of compliance therapy in improving quality of life of people
with
schizophrenia.
Participants
received
eight
weekly
sessions
of
adherence therapy or health education, each lasting about 30 and 50
minutes. This study found that adherence therapy did not improve
compliance nor other variables tested in this study. The negative result of
these studies may be attributed to the fact that the duration of
intervention
was
short
and
measurement
of
compliance
was
not
sophisticated. Because both studies are quantitative research, they fail to
adequately explain the complexity of medication compliance behaviour and
are only able to explore a small number of variables. (Kikkert et al. 2006)
Unlike the result found by Gray et al.’s (2006) and O’ Donnell et al.’s
(2003), Maneesakorn et al. (2007) in a quantitative research and the use
of randomised controlled trial carried out in a psychiatric unit in Thailand
using sample size of 32 patients who were randomly selected to either be
in the experimental group who received eight sessions of adherence
therapy lasting eight weeks for 15 to 60 minute per session or the control
group who received treatment as usual for the same duration of time. The
aim of the study was to assess the effectiveness of adherence therapy on
people with schizophrenia. The finding of this study reveled that adherence
therapy had a positive influence on psychotic symptoms, attitude towards
10
and satisfaction with medication. It was found in this same study that
similar to Gray et al.’s (2006) finding, compliance therapy did not improve
general functioning. Generalisation of this study may be restricted due to
small sample population who also had slightly lower symptoms and higher
general functioning compared with the participants in the study conducted
by Kavanagh et al. (2003) and O’ Donnell et al.’s (2003) where
participants were from psychiatric intensive care unit. Additionally a single
therapist was used for the whole sample of 32 participants and the degree
of adherence of the patients before entering the trial was not known.
Mcintosh et al. 2009 state that there is lack of evidence to support the
efficacy of compliance therapy.
11
The role of mental health nurse
The focus of this theme is to review the role of mental health nurses in
medication compliance and to examine if medication management training
package for nurses can optimize compliance with medication and clinical
outcomes in patients with mental illness.
Gray (2004) conducted a quantitative research study designed as a cluster
randomised controlled trial with sample size of 60 CMHN (community
mental health nurse) who were randomly selected in two mental health
care providers in London. The CMHN were required to pick two patients
each from their caseload for the trial. The aim of the study was to find out
whether medication management training is better than treatment as
usual in improving clinical outcomes for patients with schizophrenia. The
CMHN received 80 hours Medication management training programme
which was delivered over 10 weeks. Data was collected at baseline and
again at 26 weeks after training Using PANSS (positive and negative
syndrome scale) which has reputable construct validity (Kay et al. 1989 as
cited by Gray 2004). Result found that nurses who had received
medication
management
training
produced
a
considerably
greater
reduction in clients ‘general psychopathology compared with treatment as
usual at the end of the six-month study period. The positive result in this
study may have been influenced by the fact that nurses had a choice of
which patients to choose, so, they might have had a tendency to pick
clients whom they had good relationship with or whom they thought might
do well, for this, result can not be generalized.
This result is further
verified by Harris et al. (2009) in another cluster randomised controlled
trial which involved convenient sample of twenty-eight pairs of CMHN from
12
NHS Trust in England aimed at investigating the effects of medication
management training program on a randomly selected group of patients
from their caseload. Data was collected using five assessment tool chosen
for their clinical utility and ease of administration and these measures
have been widely used in research studies. The training lasted ninemonths .The result of this study found that as a result of the training
received by the mental health nurses there was positive outcome for
patients. However it should be noted that only 3 day training was given to
the nurses on how to use the assessment measures and this could be a
threat to internal validity, the time frame of the study is too short to
realize medication related changes and there was no “blind” assessment of
service user level outcomes. Similarly Gray, Wykes and Gournay (2003)
conducted a qualitative research with convenient sample size of fifty-two
nurses selected from two large mental health care providers in London,
England. The aim of the study is to investigate whether medication
management training is effective in improving the clinical skill of CMHN.
The study design had an inside subject repeated measures design. Data
was collected pre and post training using knowledge about medication
management questionnaire. Result of this study was positive as there was
a significant improvement in the medication management skill of the
participants. This result may have been influenced by the method of data
collection which involved role play before and after training. Anxiety about
being videotaped during role-play may have reduced post training
therefore yielding a positive result.
The
findings
of
the
above
studies
may
suggest
that
medication
management training equips nurses with the clinical skills and knowledge
that is needed to promote compliance in psychiatric patients.
13
Conclusion
The purpose of this literature review was to investigate strategies to
overcome medication non-compliance in mental health. The major cause
of
relapse
in
mental
health
is
Non-compliance
with
antipsychotic
medication. Patients decision not to take their medication as prescribed is
influenced by various factors which include intolerable side-effects, cost of
medication,
psychotic
hallucinations,
social
explanations
pressure
and
which
lack
of
include
insight.
delusions
A
number
and
of
interventions to promote compliance have been tested and some of the
outcomes of this intervention within the themes are contradictory.
Educational intervention was tested from group and individual perspective.
Educational intervention was found in some studies to improve insight,
knowledge about illness and some aspect of satisfaction but not important
variable like compliance. However the study conducted by Maneesakorn et
al. (2007) found that educating patients about their illness and medication
significantly improved compliance. Merinder et al. (1999) concluded that
educational intervention without behavioural elements do not seem able to
reduce relapse. Worthy of note in all of these studies however is their
intensity and short duration. Also these studies make use of few sample
population and their results can not be generalized.
Compliance therapy intervention proved to be successful in the study done
by Maneesakorn et al. (2007) however the studies conducted by Gray et
al.’s (2006) and O’ Donnell et al. contradicts this finding as it found that
compliance therapy intervention did not improve compliance. This could be
14
as a result of both studies being quantitative research they fail to
adequately explain the complexity of medication compliance behaviour and
are only able to explore a small number of variables. (Kikkert et al. 2006).
The positive result found by maneesakorn et al (2007) suggests that that
compliance therapy has prospective to improve compliance.
The role of the nurse theme found that there is overwhelming evidence to
prove that nurses who are trained in medication management are able to
improve medication compliance in patients with psychiatric illness. Based
on these findings, it is important to train nurses to be able to deliver
compliance therapy to patients as they spend more time with patients than
other health professionals. (Maneesakorn et al. 2007) There is a need to
develop a more effective intervention capable of
promoting medication
adherence in people with mental illness as the few intervention that are
available have little effect on patients compliance. It has been found that
the rate of relapse in mental illness is high and the revolving door
syndrome is a huge problem in the provision of mental care
15
Recommendations
During this review the author found that duration and intensity of the
reviewed interventions are usually short. It would be beneficial to carry out
more intense interventions over a longer period of time. More qualitative
researches are also needed in this area. There is a need to carry out
studies on patients with other forms of psychiatric illness other than
schizophrenia. There is a need for more research to be conducted in the
republic of Ireland as only one research was found to have been conducted
in the republic of Ireland by the author during this review. There is also a
need to train all psychiatric nurses in medication management training.
16
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